A new report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward higher-priced medications and restricting their options for obtaining prescriptions.
The investigation, which spanned over 32 months, precedes a hearing featuring executives from some of the largest PBMs in the country. This report was obtained by the Wall Street Journal.
PBMs serve as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical manufacturers and determining patients’ out-of-pocket expenses. The three largest PBMs in the U.S. — Express Scripts, OptumRx (a unit of UnitedHealth Group), and Caremark (owned by CVS Health) — control around 80% of prescriptions filled in the country.
According to the committee’s findings, these managers have established preferred drug lists that prioritize expensive brand-name drugs over more affordable generic options. The report provides an example from Cigna, which indicated in internal communications that patients should be discouraged from considering cheaper alternatives to Humira, an arthritis and autoimmune treatment priced at $90,000 annually, despite the existence of a biosimilar costing half as much.
The report also revealed that Express Scripts informed patients they would incur higher costs by filling a prescription at a local pharmacy instead of through its affiliated mail-order service, effectively limiting patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that increased consolidation within the industry has allowed the six largest PBMs to control nearly 95% of all prescriptions in the U.S. The FTC’s findings highlight concerns over the considerable influence these leading PBMs have on patients’ access to affordable medications, suggesting that their practices may favor their own affiliated businesses and create conflicts of interest that could disadvantage independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan remarked that the intermediaries are “overcharging patients for cancer drugs,” generating excess revenue exceeding $1 billion.